Deaths due to COVID-19 surpassed 210,000 last week, just as President Trump prepared to leave Walter Reed Medical Center, where he was receiving care after himself contracting the virus.
This utter failure to contain the virus across the country and within the inner circle of the Trump administration is rooted in a deep misunderstanding of public health and an undervaluing of how the field’s leaders and its tools can tackle major health challenges. The COVID-19 pandemic has brought the dire implications of this decades-old way of thinking into full view.
As far back as 1988, a report from the Institute of Medicine lamented, “This nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray.” The problem: People occupying public health leadership positions in states and in the federal government have had limited, and in many cases zero, public health training. The government has unwisely tended to value physicians and other people with clinical medical skills for these positions — a preference that continues today. This is unfortunate, because practicing medicine on individuals is quite different from guiding the health of entire populations.
Dr. Scott Atlas, President Trump’s new COVID-19 adviser, is a radiologist. His training and professional experience is in diagnosing diseases with imaging technologies. He is now charged with advising Trump on national prevention strategies as well as reopening schools and businesses. Atlas doesn’t have expertise in any of this. Calling out this disconnect, nearly 100 scientists have judged Atlas unqualified for the role, declaring his public comments on COVID-19 misleading and harmful.
Similarly, the Trump administration has tapped the White House Medical Unit to oversee tracing of COVID transmission within the White House inner circle, rather than relying on trained contact tracers from the Centers for Disease Control and Prevention. Led by Dr. Sean Conley, the official White House physician, who is trained in trauma medicine, the White House Medical Unit is focusing on contacting people who were close to the president during the two days before his positive test result. But it apparently is not aggressively tracing the contacts of those who attended and worked the Sept. 26 event celebrating the Supreme Court nomination of Judge Amy Coney Barrett. Attendees were mostly unmasked and clustered closely together; at least 12 of them have since tested positive. Expert contact tracing of such events is widely recognized as one of public health’s most powerful tools to break webs of transmission.
The appointments of Dr. Atlas and Dr. Conley are only the latest outcomes of the misconception that public health leadership requires no public health training.
As a coalition of trained public health professionals (one of us is an MD who is also trained in the practice of public health), we argue that medical training alone does not prepare anyone to serve as a public health leader. Relying on clinical expertise alone — particularly when the clinical expertise is not even relevant to infectious disease transmission — makes no sense.
Engineers are hired to do engineering. Physicists are hired to do physics. Oncologists are hired to treat cancer patients. And public health experts should be hired to lead public health.
Universities across the country produce hundreds of public health graduates each year. As an academic discipline, public health focuses on improving the health of communities. We train in epidemiology, biostatistics, policymaking, communications, and leadership and management. Several of us specialize in how to evaluate programs and policies, streamline supply chains, design behavior change interventions, and curb the spread of disease across communities. We learn how to prevent poor health outcomes through policies and systems.
Alternatively, those in medicine — the discipline given the most credibility throughout this pandemic — train in anatomy, physiology, pharmacology, and biology. Doctors learn how to treat illness in patients through individual clinical care. Sure, many specialize in topics relevant to infectious pathogens, but the focus remains on treatment of the individual.
To paraphrase the late Dr. William Bicknell, former Massachusetts Commissioner of Public Health: Bad doctors kill individual patients and bad public health professionals kill populations. The reverse is also true: Highly skilled doctors save the lives of individual patients and highly skilled public health professionals save the lives of populations.
For more than 30 years, health policy experts have criticized our health system for overemphasizing clinical interventions over prevention. Focusing disproportionately on medical treatment distracts policymakers from structural causes of health inequities that make the US much more vulnerable during a pandemic. In their 2013 book, “The American Health Care Paradox,” Elizabeth Bradley and Lauren Taylor argued that we spend so much on health care and get so little in return because we don’t invest in factors outside the clinical setting that impact our health. The authors urge spending less on health care and more on social and public health interventions.
Consider New Zealand, which the global community has largely acknowledged is “crushing the curve” of the coronavirus. Dr. Ashley Bloomfield, the leader of that country’s response and a professional with advanced public health training, credits this success to moving quickly, isolating the majority of the population, and following World Health Organization guidelines. He also recognized that “implementing this strategy would have significant economic costs, but so would a major outbreak.”
What could the US COVID-19 response have looked like had it been rooted in public health prevention methods rather than waiting for — and possibly rushing — medical treatments? How many lives could have been saved? How many lives still can be saved?
As we grapple with the biggest public health crisis of our lifetime, it seems almost too obvious to point out that trained and experienced public health experts must be among those leading the way. Just as we all need, as individuals, the best possible clinical care, Americans need the best possible public health leadership. This is true during COVID times and it’s also true during ordinary times.
Kathleen Banks is a doctoral candidate at Boston University School of Public Health and the policy and advocacy chair of the DrPH Coalition. Ashley Bieniek-Tobasco is a research assistant professor at the University of Illinois at Chicago School of Public Health and serves on the executive board of the DrPH Coalition. Eric Coles is the president of the DrPH Coalition. Ans Irfan is a faculty member at the Milken Institute School of Public Health and the policy director at the DrPH Coalition. Kate Mitchell is a doctoral candidate at Boston University School of Public Health.